Pattern of Antidepressant Use in Bipolar Disorder
Dear Carolyn --
As for "what now", well, I wouldn't presume to tell you just what to do, but there are some general guidelines that might apply to you given your experience so far as you relate it here. They are my two most basic principles of bipolar med' management:
#1. Rely on mood stabilizers. In your case this means keep sampling around the mood stabilizer family. There are now at least 5 clearly recognized med's in this group: lithium, Depakote, carbamazepine (Carbatrol, Tegretol), lamotrigine and topiramate. Only the last is still just a little uncertain. That leaves you four "for-sure's". Try them all at doses you can tolerate, and try mixing at least 3 together if that's what it takes for symptom control (assuming, you see, that the low-dose strategy, defined by what you can tolerate without too much in the way of side effects, keeps you from really having trouble with med's despite their number).
#2. Watch out for antidepressants. Basically the only time I feel comfortable using an antidepressant anymore, in people with clear bipolar disorder, is if they have a pure depression. That means sleeping 10-14 hours a day -- no insomnia allowed, that's a hypomanic symptom. It means no energy/anxiety symptoms -- only fatigue, listlessness, low energy, low motivation. I find this "pure" form pretty rare, anymore. Most of my patients, anyway, have mixed states -- and that' precisely where to watch out for antidepressants. If I use them at all, it's very low doses, and start the taper off almost as soon as some response appears; only if the person repeatedly becomes depressed doing that would I consider staying on the antidepressant.
So, that's the strategy: keep trying, keep going, you have a long way to go to exhaust all the possibilities. It's hard to search and search, but you often find something that really works.
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